Drug Abuse

Prison and AIDS

A review of the VIIth International Conference on AIDS

By Kate Dolan

Prison populations contain a disproportionate number of people who are likely to be at risk of HIV infection through their sexual and drug using behaviour. Also prisons are places in which HIV risk behaviour may be encouraged, but at the same time they present considerable difficulties in terms of carrying out research and implementing measures.

The theme of the Seventh International Conference on AIDS held in Florence was Science Challenging AIDS, based on the three principles of understanding, planning and application.

But with only one oral presentation on prisons from over 1,500 at the conference and just 24 posters out of 3,000, specifically on prisons, it is obvious a serious gap existed in the information presented at the conference.

One of the eleven parallel sessions in the ‘Communities Challenging AIDS’ series was devoted to AIDS in prisons. Since these parallel sessions do not appear in the abstract books I will review them at length here. The presentations which are documented in the abstract books, have been organised under the following headings for the purpose of this review; transmission, prevalence, risk behaviours, risks factors, care and treatment and education.

Parallel Sessions

The session on ‘AIDS in Prisons’ had eight presentations from seven countries and concluded with a heated debate.

America

Tay Ashton, from the activist group ACT UP (AIDS Coalition To Unleash Power) in Los Angeles, described the experiences of American prisoners with AIDS and distributed a list of demands for prisoners’ rights. One million people are in American prisons and there are 5,411 cases of AIDS in the prison system. AIDS is the leading cause of death in New York prisons.

Examples of ACT-UP’s demands are:

for prisoners to have access to condoms and dental dams (latex squares used during cunnilingus) to prevent the sexual transmission of HIV, and for bleach and syringes to prevent unsafe needle use.

Australia

Mike Ross from the National Centre in HIV Social Research, in New South Wales, talked about peer education of inmates where Trusties play a key role, and the distribution of Milton tablets for syringe sterilisation that has been undertaken. Prisoners have access to methadone maintenance programmes.

Unfortunately a prison officer was stabbed with a blood filled syringe and had seroconverted. The State Government responded by removing virtually all personal property from prisoners. Œ‘his in turn led to state wide rioting which caused massive damage, estimated to have cost $35m.

Wide scale HIV testing has been undertaken since November 1990 and a very low level of HIV infection among inmates in New South Wales was found. One study of injectors in Sydney revealed that 45% had been in prison, and of these 74% had injected and the majority (75%) shared syringes. Sexual activity in prison was reported by 12% of the males.

A productive four day National conference on prisons and HIV was held in Melbourne last November. An edited book of the presentations made at the conference is available and includes a review of the limited international data on HIV risk behaviours in prison by Matt Gaughwin (Norberry et al 1991). A comprehensive communique was produced, and endorsed, by the participants at the conference. One suggestion in the communique was that ‘consideration should be given to a careful time limited evaluation of a pilot strict needle exchange program’ in prison. The communique, distributed to every politician and appropriate Federal Ministers in Australia, has contributed greatly to the debate.

Sweden

Kerstin Kall from the Socialmedicinska Haktesprojektet, reported that of the 1,766 injecting drug users who were in the remand prisons in Stockholm between 1987 and 1990, 184 or 10.4% were HIV positive. Although there was little difference between the rates of infection for male and female prisoners, there were striking differences between the rates for amphetamine and heroin injectors. Over 80% of IDUs inject amphetamines and about 5% of those were HIV positive, while over 30% of primary heroin injectors were positive.

Methadone maintenance is not initiated in prison and is usually withdrawn when drugs users are incarcerated, because of the rules of methadone programmes. Given the high rate of infection among the heroin injectors then possibly the rules need revising.

Drug using inmates are pressurized by other inmates to be regularly tested for HIV and be open about the results. This would negate any chance of confidentiality and perhaps the peer involvement needs redirecting. Kall then suggested that prison was a favourable setting for HIV testing, because people are ‘available for supportive talks and prisoners are unable to use drugs for flight and denial’. I would suggest that this statement needs substantiating as it is somewhat incongruous with the findings from other countries, many of which report negative experiences of HIV testing and significant levels of drug use in prison.

Kall suggested that male homosexual activity is virtually non existent in Swedish prisons. There are several factors that may be influential, such as short sentences, possibilities to go on leave and to have conjugal visits. It would be useful to know whether these factors do influence the level of sexual risk behaviour. HIV positive inmates are integrated in the prison system and those in the final stages of AIDS may be pardoned.

United Kingdom

Roger Ralli (Home Office) outlined the educational efforts of the Prison Department; a video for staff and another for inmates had been produced. He referred to a recent report on the experiences and needs of prisoners with HIV (Miller and Curra1991). The report surveyed 31 positive inmates. Twenty six interviewees felt able to cite the source of their infection. Injecting drug use was nominated by 15 people and two stated that they had acquired HIV by sharing syringes during a previous prison sentence.

The manual, ‘HIV and AIDS, a multidisciplinary approach in the prison environment’ had been produced (HM Prison Service Medic 1990). The Home Office had collaborated with an AIDS Charity, The Terrence Higgins Trust to produce a leaflet on HIV and AIDS to be distributed to all prisoners. A brokerage scheme has been established which connects drugs agencies with specific prisons.

Members of the audience questioned Ralli over the Department’s reluctance to provide practical measures such as condoms and bleach or other suitable disinfectants. Ralli responded by saying that there could be an election this year. I assume that he meant to introduce such measures would lose votes for politicians. The policy, Viral Infectivity Restrictions, that segregates and restricts the activities of HIV positive prisoners in England and Wales will be reviewed.

The author (Centre for Research on Drugs and Health Behaviour) presented information on HIV and English prisons obtained from evaluating syringe exchange schemes (Stimson et al 1988, Dolan et al 1990b, Donoghoe et al 1990, Dolan et al 1991a and Donoghoe 1991). Five studies of over 1,000 injectors interviewed in the community about their last period in prison found high rates of incarceration are experienced by drug injectors, with between 55% and 76% having been imprisoned at some time and that 20% of IDUs are imprisoned annually. The levels of injecting and syringe sharing in prison have remained constant over the last four years. Between 25% and 30% of IDUs had injected when last in prison. For those injecting in prison, the sharing rated ranged from 62% to 75%. Such levels of syringe sharing were occurring in the community 5 years ago, but have steadily decreased to about 15% to 20%.

When in prison, HIV positive injectors were significantly more likely to share syringes than those who were negative or untested (Dolan K et al 199). About 80% of those sharing syringes in prison had made some attempt to clean the injecting equipment. The most common method was to flush or rinse the syringe in water, which would not adequately disinfect it.

Between 6 and 10% of injectors reported having had sex when last in prison. Half of the males who were sexually in prison said they would have used condoms if available. All the males who were not sexually active in prison said they would not have had sex even if condoms were available. One reason the Home Office gives for not supplying condoms in prison is that to do so would increase dangerous behaviour. An evaluation of condom provision could resolve this debate. Between 6% and 7% of drug injectors reported that they had shared tattooing equipment when last in prison.

Spain

Enrique Garcia-Huete (Institute Luria) had compared official figures to these found .: from non-government research and revealed some interesting discrepancies. The official figure report that 46.8% of prisoners are IDUs and 24.2% are HIV positive. However, independent research had found 70% of prisoners were IDUs and the prevalence of HIV infection ranged from 30% to 40%. Bleach and condoms are available in prison.

Italy

Luciano dell’Agnol from UDAVH, gave a personal view of the plight of Italian prisoners with HIV and AIDS. Some prisoners with AIDS in Florence and Turin had begun a hunger strike and were refusing medication in order for prisoners with AIDS to be considered for compassionate release.

Ora1 and poster presentations:

Transmission of HIV infection in prison

One outstanding poster by Castro at the conference illustrated the contribution of prisons to the epidemic, as it documented seroconversion in prison. Baseline testing of 808 American inmates found 3.34% were HIV positive in 1988 compared with 3.99% of 501 inmates in 1989. HIV testing of 2,459 inmates who had been incarcerated for one year found 80 or 3.25% were positive. At least eight of 2,390 inmates (0,33%) had seroconverted in prison. Castro concluded that the need for intensified HIV prevention is indicated and that condom availability and needle disinfection options should be carefully explored (abstract number MC 3067).

Prevalence of HIV infection in prison

De Paula reported that 28.1% of 334 consecutive Brazilian female entrants to prison were HIV positive. Seropositivity was significantly associated with high risk sexual partner, being an injector and having received blood transfusions (MC 3002).

Weisfuse surveyed 2,236 inmates entering New York City prison system and found 18.5% (413) were positive. There were higher HIV rates for females (25.8%) than males (16.1%), for drug users (25%) than non users (14%) and for heroin injectors (43%) than non heroin users (15%) were found. He concluded that about 12,500 seropositive individuals were incarcerated in 1989, approximately 10% of the estimated number of seropositive individuals in New York City. Prison, therefore, would be an ideal frontline institution to provide HIV prevention services, clinical care and drug treatment (MC 3265).

Soldini found significant changes in the prevalence of HIV among Italian prisoners over five years. In 1985, 24% of prisoners were HIV positive but in 1990, the prevalence had more than doubled to 52% (MC 3236). Dirceu measured the HIV prevalence among 414 children at a juvenile detention centre in Brazil and four (1.2%) of the male children aged between 12 and 16 tested positive. (WD 4237). Bley compared HIV rates among inmates (11.5%), to needle exchange clients (4.8%) and to drug treatment clients (1.6%) in Seattle (WC 3362).

The only oral presentation at the conference reported on a study of HIV infection among detained minors in Los Angeles it was found that; 0.26% of 751 minors in 1989 and 0.08% of 1,219 in 1990 were positive (WD 109). Del Mistro found 12.2% of 361 clients of drug treatment centres, 20.3% of 275 injectors and 2.4% of 332 non injecting prisoners were HIV positive in Italy. (WC 3315). Beylot found 25% of injecting drug users at Bordeaux-Gradignan prison in France were HIV positive (WD 4195).

Saliva testing of 385 ex-prisoners in England by the author found high rates of HIV infection among female (15.5% n=45) and male injectors (7.7% n=103). The presence of HIV was detected in one of 29 non injecting female ex-prisoners, (3.4%) and in three of 188 non injecting heterosexual males (1.¢%) (WC 3321).

Risk Behaviours

A study of 452 ex-prisoners in England by the author interviewed within three months of being released found 27% of 168 injectors had injected in prison and the majority (73%) had shared syringes. The level of syringe sharing before being imprisoned was 45% while 23% reported sharing after being released. Many attempted to clean their injecting equipment, but this occurred less often in prison and by less effective methods of sterilisation. Diverse sexual activity was reported by 10% of the sample and included heterosexual vaginal intercourse, both active and passive homosexual anal and oral sex. Although about one reported using condoms in prison, they are not available in English prisons (WC 3321).

Zeljkovic reported that three quarters of 1,754 incarcerated adolescents in Los Angeles reported previous illicit drug use and the average age of first use was 13 years. IV drug use was reported by 4%, with heroin being cited as the main drug. Of those injecting, 60% were sharing syringes prior to incarceration (WD 4194). Baker presented another paper on the same study and showed that virtually all minors (97%) reported being sexually active prior to imprisonment. Their average age was 16.3, the average age of sexual debut was 13.1 years and 41% had more than 10 partners. Of the 18 males who had sex with men, over 60% (12) had more than ten partners. About one third reported some condom use and 13% reported having engaged in active anal sex. Exchanging sex for money or drugs was reported by 7% of the female and 12% of male minors (MD 4098).

A survey of334 detained minors in Los Angeles found 17% of males and 36% of females who were sexually active had a history of sexually transmitted diseases (WD 4238).

Risk factors for HIV infection

Martin conducted a cross-sectional study through Spanish prisons of 19,946 people to examine the risk factors which determine HIV infection. Six risk factors were identified with IVDU being the most important. Tattooing was also important, but homosexual relations and blood transfusion were not (WD 4236).

Care and treatment of HIV positive prisoners

Lawst reported that incarcerated women in Kentucky, America, with all stages of HIV disease were provided with direct access to a full range of primary care (MD 4248), while Beylot described the health care of 160 HIV positive prisoners in France (WD 4195). Likewise Emmanelli described the care of HIV positives in the largest European prison, where 1,025 of 5,000 prisoners are HIV positive (WD 4232).

A fortnightly HIV medical clinic was established at Saughton Prison, Edinburgh in August 1989. By December 1990, only 8% of 501 HIV patients had been seen. However for 11 it was their first attendance at a clinic and 28 were seen after being discharged. Prisoners had access to AZT trials. The system ensures similar availability of medical care to that in the community (WD 4233).

Scheib identified and followed 34 people with AIDS and 40 symptomatic individuals who were released from correctional facilities in America. A high rate of non compliance with medication and recurrent substance abuse was noted, with over 80% returning to substance use. They called for systematic health care planning prior to release (WD 4234).

The author found that many of the ex-prisoners interviewed in England who were or wereassumed to be HIV positive reported they had received negative treatment, stigmatization, exclusion from work and physical hostility. Only 16% (n=63) reported they received both pre-and post- test counselling (WC 3321).

Education

Hernadez established the baseline knowledge of American inmates and, with their input, designed treatment protocols for HIV positive inmates, developed peer education programmes in Spanish and English and produced a video. One beneficial outcome was an enhanced relationship between infected and non infected inmates. (WD4235) .

Roy studied the feasibility of group interventions using instructional games in a medium security Canadian male prison.

Although IDUs were targeted, only 47% had injected at least once but all 45 participants said they would recommend the session to another inmate. It may be necessary to reach IDUs through other inmates (WC 3307)

The effectiveness of two educational approaches, ‘empowerment’ and ‘didactic’, were compared for women in a New York City detention centre. Those who atiended the empowerment sessions were significantly more likely to feel they knew a lot about AIDS to agree they could protect themselves and to know the specific risks facing incarcerated women. Also the ‘empowered’ women were more likely to report they had learned new ways to talk to their partners about sex and how to access services in jail, which are two important skills (MD 4249).

Firpo attempted to increase the perceived vulnerability to HIV and to reduce HIV risk behaviours of the incarcerated adolescents in Los Angeles. A videotape was created by peers and shown to a selected group of high risk adolescents. When followed up, over half of those involved in making the video had an increased sense of perceived vulnerability to HIV while 76% of the minors had decreased their sexual risk behaviour (WD 4255).

Conclusion

The small number of presentations concerned with prisons at the Seventh International Conference on AIDS is unsatisfactory. This probably reflects the lack of research and action in this important area. An international, or at least European, conference on prison and HIV/AIDS would draw together all available data. For example many presenting papers on drug use also made some brief reference to prisons. Areas where more research is needed would be highlighted and then systematically collected. My personal experience of research in this area leads me to believe that international collaboration, similar to the W.H.O. study of injectors in 10 countries, is required to overcome some of the political stagnation.

Few countries were able to report on the existence of efforts to prevent the transmission of HIV in prison by supplying condoms or bleach. No one reported on the effectiveness nor acceptabilty of such measures. It is crucial that these measures are evaluated to ascertain whether the spread of HIV is being affected.

According to Soldini the situation with regard to HIV infection in Italian prisons is alarming. One consistent finding to emerge was the connection between IDUs, HIV and prison. Imprisoned injecting drug users were frequently reported as having high rates of HIV infection. The most important risk factor which determined HIV infection in Spanish prisons was intravenous drug use.

The extent of the prevalence of HIV infection within prison system needs docuemtning and compared with rates in the community. A’ithough it is more difficult, it is imperative to collect data that measure serconversion in prison.

In terms of the role prison plays in the epidemic, we are still very much at the stage of trying to understand the connection and contribution of prison.

(Underlined references were presented at the conference)

AIDS Matters 1991 No.4 National AIDS Trust, London.

Baker, C.J., Morris, R., Huscroft, S., Re, O., Zeljkovic, S., Essex, A. Survey of Sexual Behaviours as Risk Factors in Incarcerated Minors. MD 4098

Barbarini, G., Soldini, L., Capelli, D., Balossi, A., Folatti, L., Po,a Gianiuigi, Chiapparoli,L. Changes of prevalence of HIV infection in normal and at risk population (t985-1990) in Northern Italy. MC3236

Beylot, L., Lacoste, D., Benezech, M., Rager, P Health care for HlV-positive patients at the Gradignan Prison (Bordeaux. France). WD 4195

Bley, L.D, Harris, N.V., Gordon, D.C., Fields, M.J. HIV and related risk behaviours among jail inmates and needle exchange and drug treatment clients.WC 3362.

Buscroft, S., Baker. C.J., Morris, R., Re, O., Ze4kovic, S., Perez, M. Survey of sexually transmitted diseases as HIV risk factors in incarcerated adolescents. WD 4238

Castro, K., Shansky, R., Scardino, V., Narkunas, J., Coe, J., Hammett, T. HIV transmission in correctional facilites. MC 3067.

De Paula, M.D., Lorenco, R., Queiroz, W., Hughes, V., Schechtmann, m., Castilho, E. and Johnson Jr, W. Prevalence of HIV seropositivity and potential risk of vertical transmission at the Sao Paulo Female state prison. MC 3002.

Del Mistro, De Marzi, L., Bandettini, G., De Rossi, A., Chieco-Bianchi, L. Patterns of HIV-1. HTLV-1/11 and HIV-2 in intravenous drug abusers (IVDA) and in prisoners. WC 3315

Dolan, K.A, Turnbull, RJ., and Stimson, G.V. HE prevalence and Risk Behaviour of 452 Prisoners in England WC3321.

Dolan, K.A., Donoghoe, M.C and Stimson G.V. (1990a) Drug injecting and syringe sharing in custody and in the communify: An exploratory survey of HIV risk behaviour, The Howard Journal of Criminal Justice, Vol 29 No.3. Dolan K A, Donoghoe M C, Jones, S J and Stimson G V (1990b) A cohort study of clients at four syringe exchange schemes and comparision groups of drug injectors. An interim report. Centre for Research on Drus 15 and Health Behaviour, London.

Dolan K A, Donoghor G V (1991). Cohort s cliPntR snd nthPr drur, l M C, Jones S J and Stimson udy of synnge exchange injectors in England,1989 to 1990 (Report). Centre for Research on Drugs and Health Behaviour, London.

Donoghoe, M C, Dolan K A and Stimson G V

(1990) National Syringe Monitoring Study. Interim Report. Centre for Research on Drugs and Health Behaviour, London.

Donoghoe M C, Dolan K A and Stimson G V (1991) The 1989 - 1990 National syringe exchange monitoring study. Ce tre for Research on Drugs and Health Behaviou , London.

Firpo, R., Dugan, P, Re, O., Baker, C.J. A for incarcerated adol

Greco, DX, De Paiva, Z., Ude, W., Ruff, A., . among children at a j Belo Horizonte. Brazi

Harris N., Gordon, D. >41\/ ~>n^~nfrited am oseman, J., Zeljkovic, S., DS education video project

scents. WD 4255

J., Pinto, J., Adams, l., Ottoni, alsey, N. Seropositivity Jvenile detention centre in WD 4237

Bley, L., Sweeney, P Why is . ., . w ~.. , zng IV Amphetamine users in the Pacitic Northwest of the United States? WC 3363

Hernandez, V., Gagnon, T. HIV/AIDS Education and Intervention Strategies within the Massachusetts State prison System. WD 4235.

H.M. Prison Service Medical Directorate. (1990) AIDS and HIV Infection. A multidisciplinary Approach. London.

Icardi, G., Bruzzone, B.M., Lazzereschi, M., Wicks, R., Rizzo, F, Guida, B., Piersantelli, N. No evidence for HIV-2 infection in Liguria, Italy. MC 3296.

Joliffe, D., iBrettle, R., Leen, CLS. IDU related HIV and prisoninedical care.- WD 4233.

Lawson, W.T., Macher, A.,Dennison, R., Fuller, R, Kale, W., Coonrod, J. The Clinical management of incarcerated women with HIV disease at the Federal Correctional Institution (FCI) and the University of Kentucky Medical Center (UKMC! In Lexington. Kentucky. USA - A Collaborative Model for Early Intervention and Continuity of Care. MD

4248

Martin, L., Grandos, A., Miranda, M. Multivariable analysis of HIV infection in Spanish prisons. WD 4236

Miller D and Curran L (1991). The Second Sentence, The experience and needs of prisoners with HIV in H.M. Prison System, England, Wales. HM Pnson Service, March

Morris, R., Baker, C., Huscroft, S., Evans, C.A., Zeljkovic, S. Two year variation in HIV risk behaviours in detained minors. WD 109.

Norberry J, Gaughwin M and Gerull S (1991) Conference proceedings, No.4 HIV/AIDS and Prisons. Australian Institute of Criminiology, Canberra.

Richie, B., Safyer, S., Freudenberg, N., Rodriguez, I., Florio, S. An evaluation of an AIDS education empowerment program for incarcerated women.

MS 4249

Roy, E., Paradis, M., Caron-Bouchard, M. Workir on attitudes toward condom and safe needle use among male injection drug users (IDU’s!: A Feasibility Study in Pnson. WC 3307

Scheib, R., McGowan, K., Sager, S., Florman, J., Bradley, O., DesRoche, A., Morgan, B., Gagnon, T., Power, M. Assessment of health care needs of individuals with AIDS/HIV symptomatic disease released from correctional facilities. WD 4234.

Turnbull, RJ., Dolan, K. A. and Stimson, G.V. (1991) Prison, HIV and AIDS: Rlsks and experiences in custodial care. AVERT Horshan England.

Weisfuse, l.B., Greenberg, B., Back, S., Makki, Thomas, R et al. HIV-1 Infection among New York City inmates, MC 3265.

Xavier, E., Chieze, E, Raffin, R., Lemaire, M.H., Colin, M., Gentilini, M. Taking care of prisoners infected by HIV or suffering from AIDS. and training of personnel. WD 4232.

Zeljkovic, S., Huscroft, S., Baker, C.J., Re, O., Morris, R., Aquino, K. Survey of Drug Abuse behaviour as HIV risk factors in incarcerated adolescents. WD 4194 m,,H.,